Articulating mechanisms with actuatable elements actuatable

ABSTRACT

The invention provides an articulating mechanism useful, for example, for remote manipulation of various surgical instruments and diagnostic tools within, or to, regions of the body. Movement of segments at the proximal end of the mechanism results in a corresponding, relative movement of segments at the distal end of the mechanism. The proximal and distal segments are connected by a set of cables in such a fashion that each proximal segment forms a discrete pair with a distal segment. This configuration allows each segment pair to move independently of one another and also permits the articulating mechanism to undergo complex movements and adopt complex configurations. The articulating mechanisms may also be combined in such a way to remotely mimic finger movements for manipulation of an object or body tissue.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a divisional of U.S. application Ser. No.12/109,333, filed Apr. 24, 2008, which is a continuation of U.S.application Ser. No. 10/997,249, filed Nov. 24, 2004, now U.S. Pat. No.7,410,483, which is a continuation-in-part of U.S. application Ser. No.10/444,769 filed May 23, 2003, now U.S. Pat. No. 7,090,637, thedisclosures of which are incorporated herein by reference

FIELD OF THE INVENTION

This invention relates to articulating mechanisms and applicationsthereof, including the remote guidance and manipulation of surgical ordiagnostic instruments and tools. In particular, this invention relatesto hand-actuated mechanisms for the remote manipulation of body tissue.

BACKGROUND OF THE INVENTION

The ability to easily remotely manipulate instruments and tools is ofinterest in a wide variety of industries and applications, in particularwhere it is desired to control movements of instruments or tools inspaces difficult to access by hand, or areas that might otherwisepresent a risk or danger. These can include situations where thetargeted site for the application of a tool or instrument is difficultto access during surgical procedures, or the manufacture or repair ofmachinery, or even during commercial and household uses, where manualaccess to a targeted site is restricted or otherwise. Other situationscan include, e.g., industrial applications where the work environment isdangerous to the user, for example, workspaces exposed to dangerouschemicals. Still other situations can include, e.g., law enforcement ormilitary applications where the user may be at risk, such as deploymentof a tool or instrument into a dangerous or hostile location.

Using surgical procedures as an illustrative example, procedures such asendoscopy and laparoscopy typically employ instruments that are steeredwithin or towards a target organ or tissue from a position outside thebody. Examples of endoscopic procedures include sigmoidoscopy,colonoscopy, esophagogastroduodenoscopy, and bronchoscopy.Traditionally, the insertion tube of an endoscope is advanced by pushingit forward, and retracted by pulling it back. The tip of the tube may bedirected by twisting and general up/down and left/right movements.Oftentimes, this limited range of motion makes it difficult to negotiateacute angles (e.g., in the rectosigmoid colon), creating patientdiscomfort and increasing the risk of trauma to surrounding tissues.

Laparoscopy involves the placement of trocar ports according toanatomical landmarks. The number of ports usually varies with theintended procedure and number of instruments required to obtainsatisfactory tissue mobilization and exposure of the operative field.Although there are many benefits of laparoscopic surgery, e.g., lesspostoperative pain, early mobilization, and decreased adhesionformation, it is often difficult to achieve optimal retraction of organsand maneuverability of conventional instruments through laparoscopicports. In some cases, these deficiencies may lead to increased operativetime or imprecise placement of components such as staples and sutures.

Steerable catheters are also well known for both diagnostic andtherapeutic applications. Similar to endoscopes, such catheters includetips that can be directed in generally limited ranges of motion tonavigate a patient's vasculature.

There have been many attempts to design endoscopes and catheters withimproved steerability. For example, U.S. Pat. No. 3,557,780 to Sato;U.S. Pat. No. 5,271,381 to Ailinger et al.; U.S. Pat. No. 5,916,146 toAlotta et al.; and U.S. Pat. No. 6,270,453 to Sakai describe endoscopicinstruments with one or more flexible portions that may be bent byactuation of a single set of wires. The wires are actuated from theproximal end of the instrument by rotating pinions (Sato), manipulatingknobs (Ailinger et al.), a steerable arm (Alotta et al.), or by a pulleymechanism (Sato).

U.S. Pat. No. 5,916,147 to Boury et al. discloses a steerable catheterhaving four wires that run within the catheter wall. Each wireterminates at a different part of the catheter. The proximal end of thewires extend loosely from the catheter so that the physician may pullthem. The physician is able to shape and thereby steer the catheter byselectively placing the wires under tension.

Although each of the devices described above are remotely steerable,their range of motion is generally limited, at least in part becausetypically only a single cable set is employed in connecting links orsegments of the steerable elements. As such, independent movement ateach link or segment is not possible. Rather, the distal links orsegments bend together as a unit or units. The steering mechanisms mayalso be laborious to use, such as in the catheter of Boury et al. whereeach wire must be separately pulled to shape the catheter. Further, inthe case of, e.g., endoscopes and steerable catheters that use knob andpulley mechanisms, it requires a significant amount of training tobecome proficient in maneuvering the device through a patient's anatomy.

Consequently, a device with enhanced remote maneuverability tocontrollably navigate complex anatomy may allow more efficient andprecise advancement and deployment of surgical and diagnosticinstruments and tools, as well as help decrease trauma to surroundingtissues, minimize patient discomfort, and decrease operative time andperhaps even patient morbidity during various surgical procedures. Itwould also be advantageous for such a device to provide a more intuitiveand facile user interface to achieve such enhanced maneuverability.

A user interface that accurately translates finger movement of the humanhand to a surgical instrument or tool is one way of achieving remoteenhanced maneuverability. Although many attempts have been made toimplement such a device, such as described in U.S. Pat. No. 5,441,494 toOrtiz; U.S. Pat. No. 5,807,376 to Viola et al.; and U.S. Pat. No.5,813,813 to Daum et al., there still exists a need for a device withimproved control and range of motion.

Thus, a device that not only provides a hand user interface, but anactuation mechanism that allows for close simulation of human handmovements to enhance remote maneuverability is highly desirable.

SUMMARY OF THE INVENTION

The present invention provides an articulating mechanism useful for avariety of purposes including but not limited to the remote manipulationof instruments such as surgical or diagnostic instruments or tools,including but not limited to endoscopes, catheters, Doppler flow meters,microphones, probes, retractors, dissectors, staplers, clamps, graspers,scissors or cutters, ablation or cauterizing elements, and the like. Thearticulating mechanism may be used to steer these instruments within abody region or to a target site within a body region of a patient, andcan further be employed to actuate or facilitate actuation of suchinstruments and tools.

In one variation, the articulating mechanism includes multiple pairs oflinks, each link of each pair being maintained in a spaced apartrelationship relative to the other link of the pair, and multiple setsof cables, with each cable set connecting the links of a discrete pairto one another and terminating at the links of each discrete pair, suchthat movement of one link of a pair causes corresponding relativemovement of the other link of the pair. The relative movement at thedistal end of the articulating mechanism corresponds to that at theproximal end.

In another variation, the articulating mechanism includes a continuousflexible member. The continuous flexible member includes multiple pairsof segments, with each segment of each pair being maintained in a spacedapart relationship relative to the other segment of the pair, andmultiple sets of cables, with each set connecting the segments of adiscrete pair to one another and terminating at the segments of eachdiscrete pair, such that movement of one segment of a pair causescorresponding relative movement of the other segment of the pair. Insome instances, the continuous flexible member may be, e.g., a catheterwith a plurality of lumens, where each cable set terminates at adifferent axial location along the length of the catheter. In otherinstances the continuous flexible member may have a helical arrangement,with each segment corresponding to one turn of the helix. If desired, aflexible linkage may be placed between the helical segments or links.

Variations of the articulating mechanism can also include segments orlinks that may include a channel for receiving a locking rod that cansecure and retain the proximal end of the articulating mechanism in afixed position. Instead of a rod, a locking sleeve may be fitted overthe proximal end of the mechanism to secure and retain the proximal endin a fixed position.

A surgical or diagnostic tool may be attached to, and extend from, thedistal end of articulating mechanisms according to the invention, or thearticulating mechanisms may be otherwise incorporated into such tools.Examples of surgical or diagnostic tools include, but are not limitedto, endoscopes, catheters, Doppler flow meters, microphones, probes,retractors, dissectors, staplers, clamps, graspers, scissors or cutters,and ablation or cauterizing elements.

A plurality of articulating mechanisms may also be combined in such away that a user's finger movements can be remotely mimicked tomanipulate an object or body tissue. In one variation, the mechanismsform a hand-actuated apparatus that includes multiple pairs of links,with each link of each discrete pair being maintained in a spaced apartrelationship relative to the other link of the pair, the linksincorporated into proximal and distal ends of the apparatus with thelinks of corresponding pairs located on the proximal and distal endsrespectively, multiple sets of cables, with each set connecting thelinks of a discrete pair to one another, and a user hand interface at aproximal end of the apparatus configured to removably secure one or moredigits of a human hand for movement, such that movement of said digitwhen secured to the interface moves one or more links of a pair at saidproximal end and causes corresponding relative movement of the other oneor more links of the pair at a distal end of the apparatus. In someinstances, at least one link of a pair is an elongate link.

In another variation, the hand-actuated apparatus includes a proximalend having a user hand interface configured to removably secure one ormore digits of a human hand for movement, such that flexion of the digitwhen secured is translated into a bending movement at the distal endeffector portion. In a further variation, the user hand interfaceincludes a finger slide where translational movement of the finger slideis translated into a bending movement at the effector portion.

The hand-actuated devices of this invention also include one or morejoints at their proximal and distal ends that have the range of motionof a distal interphalangeal (DIP) joint, proximal interphalangeal (PIP)joint, or metacarpal phalangeal (MCP) joint. In some instances, controlof movement of a proximal joint, such as a MCP joint, is independent ofcontrol of one or more distal joints, e.g., a PIP joint or DIP joint. Inother instances, movement at the proximal end of the device, e.g.,movement of one link of a pair or translational movement of a fingerslide, is proportionally scaled to the movement at the distal end of themechanism, e.g., at the other link of the pair or at the effectorportion.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-1E show perspective views of an articulating mechanismaccording to one variation of the invention, with multiple pairs oflinks connected by corresponding sets of cables. FIG. 1A shows themechanism in its natural configuration. FIGS. 1B to 1E show themechanism in various states of manipulation.

FIG. 1F is a perspective view of the distal end of an articulatingmechanism similar to that of FIG. 1A with the end manipulated intomultiple curvatures.

FIGS. 2A-2E depict end, side, and perspective views of a link for use inan articulating mechanism according to another variation of theinvention.

FIGS. 3A-3C are cross-sectional views of links similar to those of FIGS.2A-2E having variously shaped stem portions and corresponding recesses.In FIGS. 3A and 3B, the distal end of the stem portions are convex,while in FIG. 3C it is ball-shaped. The recesses are cone-shaped in FIG.3A, concave in FIG. 3B, and ball-shaped in FIG. 3C.

FIG. 3D is a cross-sectional view of links for use in an articulatingmechanism according to another variation of the invention with sphericalelements disposed between the links. FIG. 3E is a cross-sectional viewof links and spherical elements similar to those of 3D and which alsoinclude a center channel extending through and communicating between thelinks and spherical elements.

FIGS. 4A-4C are cross-sectional views of links for use in anarticulating mechanism according to a variation of the invention showingvarious modes of connecting cables to the links.

FIGS. 5A and B show an individual link for use in an articulatingmechanism according to another variation of the invention. FIG. 5A is aperspective view. FIG. 5B is an end view. The depicted link includeslumens and channels for receiving and passing through of cables andother elements.

FIGS. 6A-6C show perspective views of articulating mechanisms associatedwith a surgical clamp according to variations of the invention.

FIG. 7 is a perspective view of an articulating mechanism associatedwith a catheter according to a variation of the invention.

FIG. 8 is a perspective view of an articulating mechanism associatedwith an endoscope according to another variation of the invention.

FIGS. 9A and 9B are perspective views of an articulating mechanism usedto remotely form a retractor. In FIG. 9A, the retractor is “u” shaped.In FIG. 9B, the retractor has a triangular retracting surface.

FIG. 9C is a perspective view of an articulating mechanism according toanother variation of the invention where the mechanism is attached tothe hand of a user.

FIGS. 10A-10B show perspective views of an articulating mechanismaccording to another variation of the invention having a continuousflexible member that includes helical segments with multiple pairs ofsuch segments connected by corresponding sets of cables. FIG. 10B is anenlarged view, with parts broken away, of the helical segments shown inFIG. 10A.

FIG. 11 is a perspective view of an articulating mechanism according toyet another variation of the invention having a continuous flexiblemember with a plurality of through lumens with multiple pairs ofsegments connected by corresponding sets of cables.

FIGS. 12A-12B are perspective views of distal ends of an articulatingmechanism according to a further variation of the invention havingattached tissue ablation elements.

FIGS. 13A-13F show the distal end of an articulating mechanism accordingto FIG. 12 being remotely maneuvered to create ablative cardiac lesions.

FIG. 14 is a perspective view of a hand-actuated apparatus having fingerloops according to one variation of the invention. The apparatus isshown in an unactuated state.

FIG. 15 shows placement of a human hand in the hand-actuated apparatusof FIG. 14.

FIG. 16 is an expanded perspective view of the finger loops of FIG. 14.

FIG. 17 is a perspective view of the hand-actuated apparatus of FIG. 15in an actuated state.

FIG. 18 is a perspective view of a hand-actuated apparatus having fingerslides according to one variation of the invention. The apparatus isshown in an unactuated state.

FIG. 19 shows placement of a human hand in the hand-actuated apparatusof FIG. 18.

FIG. 20 is a perspective view of the hand-actuated apparatus of FIG. 19in an actuated state.

FIG. 21 is a perspective view of a handle of the hand-actuated deviceaccording to one variation of the invention.

FIG. 22 is a side view of the slide mechanism according to one variationof the invention.

FIG. 23 is a side view of the slide mechanism according to FIG. 18.

FIG. 24 is a perspective view of the slide mechanism of FIG. 23,partially disassembled.

FIG. 25 is a cross-sectional view of the slide mechanism of FIG. 23,taken along line B-B, showing an end joint roller having twice thediameter of a middle joint roller.

FIG. 26 is a perspective view of the slide mechanism of FIG. 23 showingthe cable connections to the rollers and a base joint according to onevariation of the invention.

FIG. 27 is a perspective view of a handle showing routing of cables.

FIG. 28 is an expanded perspective view of a molded handle of a userhand interface according to one variation of the invention, with cablestraveling through channels in the interface.

FIG. 29 is an expanded cross-sectional view of a hollow handle of a userhand interface according to another variation of the invention showingthe cables being routed by a pulley.

FIG. 30 is an expanded cutaway view of the effector portion of thehand-actuated apparatus of FIG. 14.

FIGS. 31A-31C are expanded cutaway views of the effector joints in FIG.30.

FIG. 32 is an expanded side view of the effector joints in FIGS. 31A and31B with the joints vertically oriented.

FIG. 33 is an expanded side view of the effector joint in FIG. 31C withthe joints vertically oriented.

FIG. 34 is an exploded view of an effector 111 k that forms a part ofthe effector portion of FIG. 30.

DETAILED DESCRIPTION OF THE INVENTION

Articulating mechanisms according to the invention generally includemultiple pairs of links or segments and multiple sets of cables. Thearticulating mechanisms may be made from individual, spaced apartsegments, i.e., links, or from segments formed from a continuousflexible member. The terms “link” and “segment” as used herein refer toa discrete portion or defined area at one end of the mechanism thatcorresponds to another discrete portion or defined area at the oppositeend of the mechanism. In any event, the articulating mechanism willinclude a plurality of links or segments that are members of discretepairs. The links or segments form a proximal end and a distal end, withone link or segment of each pair being situated at the proximal end, andthe other link or segment at the distal end. As further described below,links or segments formed from a continuous flexible member may be in theform of, e.g., a continuous tube, or may be situated in, e.g., a helicalarrangement, where each segment corresponds to one turn of the helix.

Each cable set connects the links or segments of a discrete pair to oneanother so that movement of one link or segment of a pair causes acorresponding movement of the other link or segment in the pair. Theability to manipulate individual links allows for the mechanism toreadily form complex three-dimensional configurations and geometries asis further detailed herein. With conventional articulating devices thatrely on cable sets or wires, it is difficult to obtain such complexgeometries because such devices are typically designed such that thesteering cables or wires pass through each segment and terminate in adistal-most segment. Thus, all the segments bend together in acoordinated response to movement of the wire or cable set, typically ina curved, or arcuate fashion. For example, the device described byAlotta et al. in U.S. Pat. No. 5,916,146 has such a configuration.

For purposes of illustration, articulating mechanisms of the inventionwill be described in the context of use for the remote guidance,manipulation and/or actuation of surgical or diagnostic tools andinstruments in remote accessed regions of the body, or for the remotemanipulation of body tissues. The terms “instrument” and “tool” areherein used interchangeably and refer to devices that are usuallyhandled by a user to accomplish a specific purpose. The term “region” asused herein refers to any solid organ (e.g., liver, kidney, brain,heart) or hollow organ (e.g., esophagus, intestines, stomach, bladder),any solid or luminal (e.g., blood vessels or ducts) tissue, or any bodycavity (e.g., sinus, pleural or peritoneal space), in their diseased ornondiseased state. Other applications of the articulating mechanismbesides surgical or diagnostic applications are also contemplated andwill be apparent to one of skill in the art. These include, withoutlimitation, industrial uses, such as for the navigation of a tool,probe, sensor, etc. into a constricted space, or for precisemanipulation of a tool remotely. Other uses include applications whereremote manipulation of complex geometries is also desirable. Theseinclude uses in recreation or entertainment, such as toys or games,e.g., for remote manipulations of puppets, dolls, figurines, and thelike.

Turning to the variation shown in FIG. 1A, articulating mechanism 100includes a plurality of links 102 that form a proximal end 106 and adistal end 108. Links A₁ and A₂, B₁ and B₂, and D₁ and D₂, respectively,are members of a discrete pair, and one link of a pair is at theproximal end 106 while the other is at the distal end 108. Links C₁ andC₂ are spacer links, as will be described in greater detail herein. Theproximal links (A₁, B₁, D₁) are connected to the distal links (A₂, B₂,D₂) by cables 104. A spacer element 112 is disposed between the proximalend 106 and the distal end 108 to separate the proximal links from thedistal links and to maintain them in a spaced apart relationship. Thespacer element 112 may be of any length appropriate to the intendedapplication, and is typically hollow so that it may accommodate all thecables 104 that connect the link pairs, as well as additional cables,wires, fiberoptics or other like elements associated with a desired toolor instrument used in conjunction with the mechanism.

The links may be of any size and shape, as the purpose dictates, buttheir form usually depends on such factors as patient age, anatomy ofthe region of interest, intended application, and surgeon preference.Links 102, for example, are generally cylindrical, and include channelsfor passage of the cables that connect the link pairs as well asadditional cables, wires, fiberoptics or other like elements associatedwith a desired tool or instrument used in conjunction with themechanism. The channel diameters are usually slightly larger than thecable diameters, creating a slip fit. Further, the links may alsoinclude one or more channels for receiving elements of attachablesurgical instruments or diagnostic tools or for passage of cables thatactuate them. The links may typically have a diameter from about 0.5 mmto about 15 mm or more depending on the application. For endoscopicapplications, representative diameters may range from about 2 mm toabout 3 mm for small endoscopic instruments, about 5 mm to about 7 mmfor mid-sized endoscopic instruments, and about 10 mm to about 15 mm forlarge endoscopic instruments. For catheter applications, the diametermay range from about 1 mm to about 5 mm. Overall length of the linkswill vary, usually depending on the bend radius desired between links.

In the variation shown in FIGS. 2A-2E, links 200 are generallycylindrical and also include stem portion 202. Links 200 may be alignedso that the distal end 206 of stem portion 202 engages a correspondingrecess 208 formed in the surface 210 of an adjacent segment. The distalend of the stem portion may be of various shapes. For example, links 200a and 200 b have convex ends 206 a and 206 b, respectively, (FIGS. 3A,3B) whereas link 200 c has a ball-shaped end 206 c (FIG. 3C). Similarly,the corresponding recesses may be of various corresponding shapes, e.g.,concave as in recesses 206 b and 206 c (FIGS. 3B and 3C) or cone-shapedas in recess 206 a (FIG. 3A), so long as it permits each link to engageone another and does not restrict the required range of motion for thearticulating mechanism.

The stem portion 202 may typically have a length between about 0.5 mm togreater than about 15 mm and a diameter between about 0.5 mm to about2.5 mm. For endoscopic applications, the stem diameter may range fromabout 1 mm to about 1.5 mm. Links 200 also include a plurality ofchannels 212 for passage of the cables that connect the link pairs, asshown in FIGS. 2A-2E. Link 500, as shown in FIG. 5, is designed with anattachment channel 502 that communicates with the segment exterior andis located toward the periphery of the segment, for mounting otherelements, e.g., energy sources (for ablation or coagulation) orfiberoptics, or flexible endoscopes, at the distal end of thearticulating mechanism. More than one link or segment may include anattachment channel so that the attachment channel may extend from thedistal end to the proximal end of the mechanism. Cables, wires,fiberoptics, flexible endoscopes and the like, may also be run through acentral channel 504 if desired.

The links or segments may be made from any biocompatible materialincluding, but not limited to, stainless steel; titanium; tantalum; andany of their alloys; and polymers, e.g., polyethylene or copolymersthereof polyethylene terephthalate or copolymers thereof, nylon,silicone, polyurethanes, fluoropolymers, poly (vinylchloride); andcombinations thereof.

A lubricious coating may be placed on the links or segments if desiredto facilitate advancement of the articulating mechanism. The lubriciouscoating may include hydrophilic polymers such as polyvinylpyrrolidone,fluoropolymers such as tetrafluoroethylene, or silicones.

A radioopaque marker may also be included on one or more segments toindicate the location of the articulating mechanism upon radiographicimaging. Usually, the marker will be detected by fluoroscopy.

Each link or segment at the proximal end of the articulating mechanismis connected to its corresponding link or segment at the distal end bytwo or more cables. Each cable set may be made up of at least twocables. As noted, movement of one pair is controlled by itscorresponding cable set and is independent of any other pair. In certainvariations, for example, a cable set will include three cables spaced120 degrees apart. By using a set of three cables to connect each linkor segment pair, each link or segment pair can be manipulated or movedin three degrees of freedom, independently of any other pairs. Bycombining a plurality of link or segment pairs, multiple degrees offreedom are achieved, allowing the articulating mechanism to be shapedinto various complex configurations. For example, the variation shown inFIG. 1F has a total of nine link pairs each independently connected bysets of three cables each, for possible motion in 27 degrees of freedom.Such multiple degrees of freedom are not available in typicalconventional mechanisms where only a single set of cables is employed tomanipulate the links.

Cable diameters vary according to the application, and may range fromabout 0.15 mm to about 3 mm. For catheter applications, a representativediameter may range from about 0.15 mm to about 0.75 mm. For endoscopicapplications, a representative diameter may range from about 0.5 mm toabout 3 mm.

Cable flexibility may be varied, for instance, by the type and weave ofcable materials or by physical or chemical treatments. Usually, cablestiffness or flexibility will be modified according to that required bythe intended application of the articulating mechanism. The cables maybe individual or multi-stranded wires made from material, including butnot limited to biocompatible materials such as nickel-titanium alloy,stainless steel or any of its alloys, superelastic alloys, carbonfibers, polymers, e.g., poly (vinylchloride), polyoxyethylene,polyethylene terephthalate and other polyesters, polyolefin,polypropylene, and copolymers thereof; nylon; silk; and combinationsthereof, or other suitable materials known in the art.

Referring to FIG. 1A, cables fixed to a proximal link travel through aspacer element 112 to connect with a corresponding distal link of thepair. As shown in FIGS. 1B-1E, movement of proximal links results ininverted, reciprocal movement of distal links. In other variation, thecables can be twisted or rotated 180 degrees while running through thespacer element 112 so that the reciprocal movement at the distal end 108is mirrored. The articulating mechanisms of this invention may beconfigured to include cables twisted in any amount between 0 degrees to360 degrees to provide for 360 degree range of reciprocal motion.

The cables may be affixed to the links of a pair according to ways knownin the art, such as by using an adhesive or by brazing, soldering,welding, and the like. FIG. 4 a shows cable 401 affixed within channel402 of link 410 in such manner. In another variation depicted in FIG.4B, a cable terminator 400 is mounted, e.g. crimped, brazed, welded, orglued, onto cable end 404 to prevent its slippage through the channel402. In a further variation, as shown in FIG. 4C, the cable terminators400 are swaged to form a chamfer within channel 402 so that a frictionfit is made between the cable end 404 and cable terminators 400.

FIGS. 10A and 10B show a variation of the invention. Rather thanindividual links or segments, the segments of articulating mechanism 130are formed from a continuous flexible member, depicted as an elongatedcoil. Each turn of the coil is a helical segment 131 of the articulatingmechanism. The segments 131 are of a thickness that allow channels 105to run through them, parallel to the axis of the coil. The helicalsegments at the proximal end 107 form discrete pairs with segments atthe distal end 109. Each segment pair is connected by its own set ofcables 111. A spacer element 113 is also disposed between the proximalend 107 and distal end 109 to separate the proximal segments from thedistal segments. The cables can be affixed to the helical segments aspreviously described.

In yet another variation of the invention, as shown in FIG. 11,articulating mechanism 132 is formed of a continuous tube 115 havingmultiple lumens 117 running through the entire length of the tube. Thecontinuous tube 115 may also optionally include central lumen 119. Cablesets may run the length of the tube and be anchored at varyingcorresponding axial locations at the proximal and distal ends with,e.g., an epoxy, or run between each segment of a pair and be anchored ator in the vicinity of each segment at the proximal and distal end. Forexample, at the mechanism proximal end 121, one cable set may beanchored at A₁, another at B₁, and another at C₁. Each cable set wouldthen be anchored at a corresponding location at the mechanism distal end123, e.g., at locations A₂, B₂, and C₂.

The cables that run between segment pairs may be precisely cut to acertain length, but if desired, may be cut to approximate that length.One method of placing the cables involves advancing the cables throughthe lumens using a pusher. A visual marker or tactile stop on the pusherwould indicate how far to advance the pusher. After the pusher isremoved, a needle may be introduced into each lumen to deposit epoxyfrom, e.g., a syringe exterior to the tube, at each cable end. Inanother method, which for example can be used with cable sets runningthe entire length of the tube, the needle may be directed to puncturethrough the wall of the tube at or near each desired cable attachmentpoint to deliver epoxy to the cable at the desired point, therebyattaching each cable to each corresponding segment pair.

Although the many of the articulating mechanisms have been illustratedin the above figures as having only eight links (four pairs), this issolely for the illustrative purpose of indicating the relationship ofthe individual device components to one another. Any number of links andlink pairs may be employed, depending on such factors as the intendedbody region of use and desired length of the articulating mechanism. Forexample, articulating mechanism 101 of FIG. 1F has nine link pairs.

Spacer links, i.e., links not connected by discrete sets of cables(e.g., C₁ and C₂ in FIGS. 1A-1E), may also be included in thearticulating mechanisms. These links can be inserted between activelinks at either the proximal or distal ends or both, and act as passivelinks that are not independently actuatable, but do allow for passthrough of cable sets to neighboring active links. Spacer links can bedesirable for providing additional length to the proximal or distal end.In addition the inclusion of spacer links at one end of the mechanismallows for the proportional scaling of movement or motion of thecorresponding other end. For example, the inclusion of spacer links atthe distal end would require a more exaggerated movement by the user atthe proximal end to achieve to achieve the desired motion at the distalend. This could be advantageous in situations where fine, delicatecontrolled movements were desired, such as, for example, situationswhere there is a risk that a user may not possess the necessarydexterity to perform the desired procedure absent such proportionalscaling of the distal end movement or motion. Alternatively, spacerlinks could be provided on the proximal end, in which case the degree ofdistal end movements would be proportionally greater than those of theproximal end, which may also be desirable for particular applications.

As noted, the articulating mechanisms of this invention may be used todirect a surgical or diagnostic instrument tool within a body region orto a target site within a body region of a patient either in its native,straight configuration, or after undergoing various manipulations at itsproximal end from a location outside the patient. After appropriateinsertion, movement of the proximal end of the mechanism, results inreciprocal movement at the distal end. Further, the resultingdirectional movement of the distal end can be inverted, mirrored orotherwise, depending on the degree of rotation of the proximal endrelative to the distal end. Also, the proximal end provides for a userinterface to control the steering and manipulation of the distal endthat is convenient and easy to use relative to other conventionalsteering mechanisms that rely on e.g., pulleys or knobs to controlsteering wires. This user interface allows for example a user to readilyvisualize the shape and directional movement of distal end of themechanism that is located e.g. within a patient based on the manipulatedshape of the externally positioned proximal end user interface.

Complex movements, including up, down, right, left, oblique, androtational movements, may be accomplished due to the formation ofmultiple pairs of segments or links connected by discrete cable sets, asdescribed above. For example, in the variation shown in FIG. 1B, themost distal link at the distal end, A₂, may be actuated, while all otherlinks remain stationary by actuation of the most distal link at theproximal end, A₁. For illustrative purposes, the distal-most link isshown to be rotated to form a right circular cone 114 a, the basediameter of which increases with such factors as increased length ofstem portions, enhanced cable flexibility, and addition of spacer links103 (e.g., C₁) in addition to the other links.

As shown in FIG. 1C, the most proximal link at the distal end, D₂, isactuated while all other links remain stationary by actuating only themost proximal link at the proximal end, link D₁. Upon rotation, the basediameter of the right circular cone 114 b is larger than cone 114 a inFIG. 1B due to the increased number of segments being actuated (therebyincreasing the slant height).

If a middle link is actuated at the proximal end, e.g., B₁, in FIG. 1D,while all other links remain straight or stationary to one another, thanonly the corresponding middle link at the distal end, B₂, will bemanipulated and may be rotated to form, e.g., a cone with curved sides116 a. Or, as shown in FIG. 1E, a larger cone with curved sides 116 bmay be formed by manipulating the distal-most link, A₁, so that allproximal links bend into a curve. All links at the distal end will thenmimic the curve, in an inverted fashion.

Although rotational movements are depicted in FIGS. 1B-1E, again, othercomplex, 3-dimensional movements incorporating up, down, right, left,and oblique movements, may also be accomplished. For example, FIG. 1Fshows the distal end 120 of an articulating mechanism having multiplecurvatures (122, 124, 126) along its length, each oriented in directionsindependent of one another. As noted, articulating mechanism 101 of FIG.1F has nine pairs of links with three cable sets each providing formovement in 27 degrees of freedom, but other configurations of linkpairs and cable sets will readily achieve similar complex movements andgeometries. The ability of portions the mechanism to bend in differentdirections at the same time and create active complex configurations isprovided by the independent actuation of each link or segment pair ascontrolled through its corresponding cable set.

The natural configuration of the segments, when connected by cable sets,is usually linear. Thus, if maintenance of a certain curvature or othercomplex configuration is desired at the distal end of the articulatingmechanism, a malleable tube slidable over the proximal segments may beshaped to keep the proximal segments, and thus, their correspondingdistal segments in a particular configuration. This may be advantageouswhere, for example, a surgeon has navigated the mechanism to a desiredtarget location and wishes to “lock” the mechanism in place while e.g.actuating a tool associated with the mechanism, or engaging in aseparate procedure altogether. By the term “malleable” it is meant thatthe tube is flexible enough so that it is capable of being shaped, butrigid enough so that it maintains its shaped form. In another variation,a locking rod may be inserted into one or more attachment channelsextending through the links or segments to “lock” the proximal anddistal segments of the articulating mechanism in place. The locking rodmay be a malleable metal bar that may be shaped and then inserted intothe attachment channels to set the proximal and distal segments into aparticular configuration, or the locking rods may be provided inpreshaped forms.

Other methods of freezing or locking the articulating mechanism in placeinclude the general use of links configured with ball-and-socket typejoints together with a tensioning cable. Examples of such systems aregenerally described in e.g. U.S. Pat. No. 5,899,425 to Corey, Jr. et al.In such systems, a cable passing through the joints is tensioned,causing the balls and sockets to lock together frictionally. The cablecan be tensioned by number of ways, including e.g. by affixing the endof the tensioning cable to a screw that is threaded into a nut affixedto the proximal end of the mechanism. FIGS. 3D and 3E illustrateball-and-socket type link systems for use in articulating mechanisms ofthe invention. As shown, in FIG. 3D, each link 300 has a recessed socket301 for receiving a spherical element or ball 302 disposed between thelinks. When a tension force is applied linearly along the axis of thelinks, the links will lock into place due to frictional forces betweenthe balls and sockets. FIG. 3E shows a link system of similarconfiguration, with each link 310 and ball 312 having aligned channels313 and 314 for the passage of a tensioning cable. Other mechanisms forlocking the articulating mechanism in place in a fixed, articulatedposition include but are not limited to those described in U.S.application Ser. No. 10/928,479, filed on Aug. 26, 2004, incorporatedherein in its entirety.

The articulating mechanism may be employed for remote manipulation ofsurgical instruments, diagnostic tools, various catheters, and the like,into hollow or chambered organs and/or tissues including, but notlimited to, blood vessels (including intracranial vessels, largevessels, peripheral vessels, coronary arteries, aneurysms), the heart,esophagus, stomach, intestines, bladder, ureters, fallopian tubes, ductssuch as bile ducts, and large and small airways. The articulatingmechanism may also be used to remotely direct surgical instruments,diagnostic tools, various catheters, and the like, to solid organs ortissues including, but not limited to, skin, muscle, fat, brain, liver,kidneys, spleen, and benign or malignant tumors. The articulatingmechanism may be used in mammalian subjects, including humans (mammalsinclude, but are not limited to, primates, farm animals, sport animals,cats, dogs, rabbits, mice, and rats).

The articulating mechanisms may generally be used in any application orincorporated into other devices in which there is a user interfaceproximally, and an actuating element distally. The user interface mayinclude the proximal end of an articulating mechanism, while the distalend may be attached to the actuating element. For example, in FIG. 6A, aremotely maneuverable surgical clamp 600 is shown. The clamp jaws 602are attached to the distal end 604 of the articulating mechanism. Theproximal end 606 is built into the clamp handle 608. A user is able toremotely position the clamp jaws 602 by manipulating the proximal end606 of the articulating mechanism. A middle portion (“neck”) 610 is alsoprovided with the surgical instrument, the length and flexibility ofwhich will vary with the application, with the neck providing thefunction of the spacer element. FIG. 6C shows another variation, whereclamp handle 632 of surgical clamp 630 extends from proximal end 634. Inother variations, the clamp jaws 602 may be exchanged for scissors orother cutting element, a dissector, a tissue grasper or needle grasper,a stapling device, a cauterizing or ablation device, and or other liketool or instrument.

In a further variation, the articulating mechanism itself may form theclamp jaws. In FIG. 6B, the clamp 612 has a user end with the proximalsegments 614 extending from pivot 616 of the clamp. The cables thatoriginate in the proximal segments 614 bifurcate into two cables each inthe area of the pivot 616 so that each cable in the proximal end maythen terminate in two separate articulating mechanisms that formopposing clamp jaws 618, 618. Thus, when a user manipulates the proximalsegments 614, the jaws 618 will remain aligned and be correspondinglyremotely manipulated. If desired, the proximal segments 614 may extendand be manipulated from one of the handles 620 of the clamp. The jawscan further be configured with particular tissue engaging surfaces, aswell as ablation elements.

In yet a further variation, the articulating mechanism can beincorporated into a catheter and used to guide the catheter, e.g., indifficult central line placements, or in percutaneous or image-guideddrainage catheter placement. As shown in FIG. 7, a catheter 700 mayinclude an articulating mechanism with the proximal end of the mechanism702 configured as an integral component of the user interface, in thisinstance, handle 706. The distal segments 708 form the distal portion ofthe catheter, and may be remotely maneuvered to guide the catheter 700as it is advanced. In another variation (not shown), the articulatingmechanism may be threaded through the catheter like a guidewire suchthat the proximal segments extend from the catheter proximal end, e.g.,either directly from the catheter lumen, or from a bifurcated wyeconnector. The distal segments may extend from the catheter tip, and thecatheter remotely guided to its target position as it is advanced.Typically, the articulating mechanism would then be removed to allowflow through the catheter. However, if the articulating mechanism thatis employed has a central lumen, its removal may not be necessary.

In the same fashion, the articulating mechanism can be incorporated intoand used to steer a flexible endoscope. In FIG. 8, endoscope 800 isconfigured such that the proximal end 806 of the articulating mechanismforms an integral part of the endoscope handle 804. The distal end 808of the mechanism would constitute all or a part of the endoscopeinsertion tube 810. Upon manipulation of the proximal segments 806, theinsertion tube 810 may be remotely manipulated.

In another variation, as shown in FIGS. 9A and 9B, the articulatingmechanism could be used as a hand-held or self-retaining retractor 900.The proximal segments 902 and distal segments 904 may extend from theretractor handle 906. Manipulation of the proximal segments 902 willmove the distal segments 904 in a reciprocal fashion. The distalsegments can be manipulated to form a variety of complex shapes, thedesired shape depending on the particular application. In operation, thedistal end can be first positioned into the desired shape and thenengaged with the target tissue. Alternatively, tissue retraction can beperformed concurrently with manipulation of the distal end, i.e., thedistal end can be engaged with the target tissue and through the act ofmanipulating the distal end, the tissue can be retracted.

A retractor typically must maintain its shape in use. Thus, theretractor may be “locked” into place using e.g. methods previouslydescribed. For example, the mechanism can include links with a ball andsocket configuration together with a locking cable (not shown).Alternatively, a malleable sheath (not shown) may be placed over theproximal segments 902 prior to their manipulation or a locking rod (notshown) may be used to fix the retractor in a particular configuration,as has been previously described. In FIG. 9A, the retractor 900 is “u”shaped. In FIG. 9B, the retractor 900 has a triangular retractingsurface. As noted, a retractor shape may be varied, depending on factorssuch as anatomical structure involved or type of surgical procedure.

In another variation, a number of articulating mechanisms can becombined in such a way that a user's finger movements can be remotelymimicked. For example, proximal ends of the mechanisms can be affixed toa user's fingers, for example, either strapped to each digit orotherwise secured to a glove that the user can wear. The distal endswill then move according to the user's finger movements. As used herein,the terms “finger” and “digit” will be used interchangeably, and referto the thumb, index finger, middle finger, ring finger, and pinky. Inthe variation shown in FIG. 9C, mechanism 950 includes threearticulating mechanisms operable by movement of a user's thumb, index,and middle fingers. As can be seen, proximal ends 951, 952 and 953 areaffixed to a user's thumb, index finger and middle finger, respectively,by straps 957. The mechanism is further secured to the user's hand bystrap 958 which secures the proximal end of spacer element 956 to theuser's wrist. Movement of the user's thumb, index finger, and middlefinger causes corresponding movement of distal ends 961, 962 and 963,respectively. Such variations may be advantageous in various surgicalsituations where gross manipulation of tissue or organs is required. Inthis as well as other variations, a protective pliable sheath can beextended over the mechanism to avoid potential damage to tissue fromindividual links or cables.

In yet further variations, the articulating mechanisms or combinationsof articulating mechanisms described above that mimic finger movement(also generally referred to herein as hand-actuated devices) and thatinclude a user hand interface at the proximal end of the device forremovably securing a digit of a human hand, may be further modified suchthat the user hand interface is also configured to removably engage withthe palm (ventral surface) of the hand. The interface generally includestwo portions, a finger portion for actuating movement and releasablysecuring one or more fingers to the interface, and a handle portionwhich partially abuts the palm and which provides another surface forreleasably securing a user's hand and fingers. The ergonomics of thisdevice configuration is particularly desirable since a user's hand maybe quickly engaged and disengaged from the device. The ability toquickly and easily engage or disengage one's hand from the device may beparticularly advantageous in, e.g., surgical settings where surgeonstypically need to swap surgical tools rapidly. Importantly, although thedevices are generally adapted for use by a human hand, and typicallyinclude three mechanisms to accommodate the index finger, middle finger,and thumb of the hand, the number of articulating mechanisms that may beincluded is not so limited, and may include as many mechanism as a usercan control at once.

The distal end of the hand-actuated devices usually includes an effectorportion that generally mimics the structure and movement of humanfingers and which is remotely actuated by corresponding movements at thefinger portion of the interface. The effector portion is typicallyconfigured to provide such gross movements as gripping and pinching, butalso provides for finer finger movements oftentimes required, e.g., forfine tissue manipulation. Thus, in surgical applications, the effectormay be used to clamp, provide traction, dissect, debride, suture, orotherwise manipulate body tissues.

Anatomically, human fingers include bones called phalanges. The indexfinger, middle finger, ring finger, and pinky have three phalanges,commonly referred to as the proximal phalanx, middle phalanx, and distalphalanx. The thumb includes only two phalanges, a proximal phalanx and adistal phalanx. Movement of the phalanges are controlled by fingerjoints that join the head of one phalanx with the base of the moredistal one. Joints at the base of the proximal phalanx (that connect theproximal phalanx to bones of the hand) are metacarpophalangeal (MCP)joints that typically allow flexion, extension, abduction, adduction,and circumduction (movement in two degrees of freedom) of the proximalphalanx. Interphalangeal (IP) joints, on the other hand, which join thedistal phalanx to the middle phalanx and/or the middle phalanx to theproximal phalanx, are typically uniaxial hinge joints that permit onlyflexion and extension (movement in a single degree of freedom).

The hand-actuated devices of this invention are typically made fromlinks adapted in such a way to generally correspond to the anatomicalstructure of human fingers and generally parallel the range of motion ofhuman finger joints, but can also be configured to provide jointmovement in any desired degree of freedom. For example, links can bedimensioned and grouped together so that they look and work similar tohuman fingers and finger joints. In that vein, links adapted tocorrespond to phalanges would be, e.g., longer than links used as partof the finger joints (MCP and IP joints). Essentially, a deviceincluding components that correspond to the general anatomic structureof human fingers and which generally parallel the function of humanfinger joints would provide much of the manual dexterity generallyassociated with the human hand.

The links representative of phalanges may be of any dimension, so longas they are capable of functioning similar to human phalanges, but aretypically longer than other links, as mentioned above, and willaccordingly be referred to herein as “elongate links”. The length of anelongate link may range from a less than a millimeter to a fewcentimeters, and in some non-medical applications, even several inches.For general surgical use, the length of elongate links corresponding toproximal phalanges may be about 22 mm, for middle phalanges about 17 mm,and for distal phalanges about 15 mm. Elongate links at the proximal endof the device will be generally referred to as “finger links” and thoseat the distal end of the device will be referred to as “effector links”.

The elongate links can take any form that can provide functionalitysimilar to a human phalanx may be used. For example, if desired, theelongate links can be made flexible. The diameter of the elongate linksmay also vary, depending on factors such as the finger that the link isbeing associated with (e.g., thumb, index finger, or middle finger) andthe device application, but will typically be from about 1 mm to about20 mm, or more than 20 mm. The diameter of a smaller elongate link maybe about 1 mm to about 3 mm, for a mid-range elongate link about 3 mm toabout 7 mm, and for a larger elongate link about 7 mm to about 10 mm ormore.

The elongate links may be made from any biocompatible material aspreviously mentioned for links, including, but not limited to, stainlesssteel; titanium; tantalum; and any of their alloys; and polymers, e.g.,acrylonitrile-butadiene-styrene (ABS) terpolymer, Delrin® acetalhomopolymers and copolymers, polycarbonate, polyethylene or copolymersthereof, polyethylene terephthalate or copolymers thereof, nylon,silicone, polyurethanes, fluoropolymers, poly (vinylchloride); andcombinations thereof, or any other suitable material known in the art.The elongate links may also be variously textured to enhance theirgripping or traction ability, as will be apparent to one of skill in theart. The elongate links themselves can be textured or a texturedmaterial can be applied to the elongate links. In certain variations,the textured material can include tractive surfaces, as disclosed inU.S. Pat. No. 6,821,284, incorporated by reference herein in itsentirety.

As previously described, phalanges are joined to one another by humanfinger joints, i.e., the DIP, PIP, and MCP joints. In a similar fashion,elongate links are connected by joints in the mechanism. As used herein,“joint” refers to discrete links or a discrete combination of linkscapable of having the range of motion of a DIP, PIP, or MCP joint. Atthe proximal end of the mechanism, the joint corresponding to an MCPjoint will be generally referred to as the “base joint” and the jointscorresponding to DIP and PIP joints will be generally referred to as“finger joints”. At the distal end of the mechanism, the jointcorresponding to the MCP joint will be generally referred to as the“effector base joint” and the joints corresponding to DIP and PIP jointswill be generally referred to as “effector joints”. The joints may bemade from any biocompatible material similar to that used for elongatelinks, as previously described.

The hand-actuated devices may be formed from a plurality of individuallyattached elongate links and joints or from elongate links and jointsformed integrally with one another. Furthermore, the links and linkcombinations used as elongate links or joints include those describedherein, as well as other suitable links and link combinations,including, but not limited to, those disclosed in U.S. application Ser.No. 10/928,479, filed on Aug. 26, 2004, U.S. application Ser. No.10/948,911, filed on Sep. 24, 2004, and U.S. application entitled“Articulating Mechanisms and Link Systems With Torque Transmission InRemote Manipulation of Instruments and Tools”, filed Nov. 23, 2004, thedisclosures of which are herein incorporated by reference in theirentirety. Links that are designed to adjust for cable bias, includingthose described in U.S. application Ser. Nos. 10/928,479 and 10/948,911,are also useful. In order to provide for increased rigidity of thearticulating mechanism and hand-actuated devices when manipulated,active links are typically fully constrained so as to resist movementdue to laterally applied forces, as is described in U.S. applicationSer. Nos. 10/928,479 and 10/948,911. The use of fully constrained linkshelps to preserve the integrity of the desired shape formed at thedistal or proximal end of a manipulated mechanism when in use, andallows force to be distributed across the desired shape. Spacer links onthe other hand are typically unconstrained. The provision of spacerlinks decreases the rigidity of the proximal or distal end in thoseareas that contain such spacer links or flexible segments, which can bedesirable, e.g., when navigating through or around sensitive or fragileanatomical structures.

As previously described, articulating mechanisms of this inventioninclude links at a proximal and distal end of the mechanism. Theproximal and distal links form discrete pairs and are connected to eachother by cable sets so that movement of one link of a pair causescorresponding movement of the other link in the pair. In the samefashion, hand-actuated devices of this invention include articulatingmechanisms having a plurality of elongate links that form members ofdiscrete pairs. The elongate links form a proximal end, or “fingerportion”, and distal end, or “effector portion”, with one elongate linkof each pair being situated at the finger portion end, and the otherelongate link at the effector portion end. Cable sets run through thejoints and connect the elongate links of a discrete pair to one anotherso that movement of one elongate link of a pair causes a correspondingmovement of the other elongate link in the pair, independent of movementof other pairs of elongate links.

The one to one correspondence of movement of elongate links may also beextrapolated to joints. As further described below, articulation of theeffector joints may be generally achieved by articulation of a basejoint and finger joints at the proximal end of the device or may beachieved by actuation of a finger slide. In some applications, it may bedesirable to scale movement of effector links and joints, to eitherincrease or decrease the movement produced at the distal end relative tothe corresponding movement at the proximal end, examples of which willbe also be provided below. As previously mentioned, proportional scalingof movement in the articulating mechanisms can in general beaccomplished by the inclusion of additional spacer links. Proportionalscaling of movement in the articulating mechanisms can also beaccomplished in general by increasing or decreasing the cable channelpattern radius in the links, at either the proximal or distal end of themechanism, as is further described in pending and commonly owned U.S.application Ser. No. 10/948,911 incorporated herein by reference in itsentirety. For example, if the radial distance of cables from centralaxis of links of the proximal end is greater than that in the distalend, the degree of bending or flex of the distal end will beproportionally greater than that of the proximal end. The result is thatsmaller degree of movement at the proximal end will produce a greaterdegree of movement at the distal end. Alternatively, if the cable radialdistance of links of the proximal end is less than that in the distalend, the degree of bending or flex of the distal end will beproportionally less than that of the proximal end, such that movement ofthe proximal end will be exaggerated relative to the distal end.Proportional scaling of movement will also typically produce scaling offorce.

FIGS. 14-17 depict a variation of a hand-actuated device in whicharticulation of the effector joints may be generally achieved byarticulation of a base joint and finger joints at the proximal end ofthe device. In FIG. 14, the hand-actuated device 1700 has a proximal end1711 and a distal end 1721. A user interface 1713 at the proximal end1711 includes a finger portion 1712 and a handle portion 1717. Thefinger portion 1712 actuates movement at distal end 1701 and releasablysecures one or more fingers to the interface 1713. Handle portion 1717partially abuts the palm and provides another surface for releasablysecuring a user's hand and fingers. Typically, a user's thumb, indexfinger, and middle fingers will be releasably secured to finger portion1712, but any combination of fingers may be releasably secured. In FIG.14, finger portion 1712 is adapted to releasably secure a user's indexfinger, middle finger, and thumb in an index finger portion 1714, middlefinger portion 1715, and thumb portion 1716, respectively.

In one variation, a user's fingers may be releasable secured orreleasably engaged to finger portion 1712 by finger loops 1509, as shownin FIG. 15. Specifically, a user's index finger, middle finger, andthumb may be releasable secured to an index finger portion 1714, middlefinger portion 1715, and thumb portion 1716, respectively.

An enlarged view of an index finger portion is shown in FIG. 16. Fingerloops 1709 may be constructed from the same materials as the elongatelinks described above, and are attached to finger links 1707A, 1707B,and 1707C by techniques well known in the art, such as, but not limitedto, fastening, e.g., such as with a mechanical fastener, welding andgluing. Extending between finger links 1707A and 1707B is distal fingerjoint 1708A, which is configured to have a range of motion similar to aDIP joint. Extending between finger links 1707B and 1707C is anotherdistal finger joint 1708B, which is configured to have a range of motionsimilar to a PIP joint. Finger link 1707C is coupled to handle portion1717 by proximal base joint 1708C, which is configured to have a rangeof motion similar to a MCP joint. The particular structure of the jointswill be addressed further below.

The hand-actuated mechanisms of this and other variations also includean effector portion for remote manipulation of, e.g., instruments,tools, or body tissues. In one variation, shown in FIG. 17, effectorportion 1701 is shown to include three effectors, 1702, 1703, and 1704,but if desired, the device can be equipped with more or less than threeeffectors. Similar to finger portions, effectors also include elongatelinks and joints. Elongate links and joints in the effector portion aregenerally referred to as “effector links” and “effector joints”respectively, and are also adapted in such a way to mimic humanfinger/hand movement. Effector links will typically correspond tophalanges, and the range of motion of effector joints will usuallyparallel that of DIP, PIP, or MCP joints. For example, in FIG. 17,effector links 1705A, 1705B, and 1705C are configured to correspond to adistal phalanx, middle phalanx, and proximal phalanx, respectively, andeffector joints 1706A, 1706B, and 1706C are adapted to parallel thefunction or range of motion of the DIP, PIP, and MCP joints,respectively.

In operation, as shown in FIGS. 15 and 17, movement of a user's fingers,e.g., an index finger, middle finger, and thumb, from an open (FIG. 15)position to a closed, grasping position (FIG. 17), correspondingly movesfinger links 1707A, 1707B, 1707C and finger joints 1708A, 1708B andeffector base joint 1708C because the user's fingers are releasablysecured to finger loops 1709 that are also attached to finger links1707A, 1707B, and 1707C. Cables (not shown) running through the fingerlinks 1707A, 1707B, and 1707C, finger joints 1708A and 1708B, effectorbase joint 1708C, handle portion 1717, shaft 1710, and effector palm1711, are actuated by the user's finger movement to produce acorresponding movement of effector portion 1701. Specifically, movementof finger joint 1708A causes a corresponding articulation of effectorjoint 1706A, movement of finger joint 1708B causes a correspondingarticulation of effector joint 1706B, and movement of base joint 1708 ccauses a corresponding articulation of effector base joint 1706C.Mirrored movement at the effector portion 1701 may be generally achievedby rotating the cables approximately 180.degree. as they travel throughthe handle portion 1717, or shaft 1710, or effector palm 1711. Mirroredmovement may be more intuitive and also desirable in some instancesbecause it allows the effector portion to, e.g., close when a user'sfingers are closed, or move right when a user's finger moves right, ormove left when a user's finger moves left. Alternatively, invertedmovement may be generally achieved by not rotating the cables. In someinstances, it may be desirable to provide a combination of mirroredmotion and inverted motion in the effector portion.

Although only a thumb, index finger, and middle finger portions aredepicted in the user interfaces of FIGS. 14,15, and 17, as well as inother figures, the invention is not so limited. Depending on suchfactors as the intended use or user preference, the interface may beconfigured to include a finger portion for releasably securing anynumber of fingers. In addition, the finger portions may be arranged onthe handle portion as illustrated in FIGS. 14-17, but may also be variedto accommodate other arrangements and positions, so long as adequateactuation of the effector portion may be achieved.

FIGS. 18-20 depict another variation of a hand-actuated device in whicharticulation of the effector joints may be generally achieved byactuation of finger slides. In this variation, as shown in FIG. 18,hand-actuated device 1800 has a proximal end 1801 and a distal end 1821.A user interface 1803 at the proximal end 1801 includes a finger portion1804 and a handle portion 1805. The finger portion 1804 includes fingerslides 1806 for actuating movement at the distal end 1821 and releasablysecuring one or more fingers to the interface 1803. Handle portion 1805partially abuts the palm and provides another surface for releasablysecuring a user's hand and fingers.

Distal portion 1802 includes an effector portion 1807 having effectors1808, 1809, and 1810. Effectors are made up of effector links andeffector joints as previously described. For example, in FIG. 18,effector 1808 includes effector links 1811A, 1811B, and 1811C, andeffector joints 1812A, 1812B, and 1812C. In particular, the function ofeffector joint 1812A parallels a DIP joint, effector joint 1812Bparallels a PIP joint, and effector base joint 1812C parallels a MCPjoint.

The user interface 1803 of this variation includes finger slides 1806 inaddition to a base joint 1813 to actuate movement of effectors 1808,1809, and 1810. In this as well as other variations, movement of basejoint 1813 mimics MCP joint movement and is capable of flexion,extension, abduction, adduction, and circumduction.

In operation, as shown in FIGS. 19 and 20, movement of a user's fingers,e.g., an index finger, middle finger, and thumb, from an open (FIG. 19)position to a closed, grasping position (FIG. 20), actuates fingerslides 1806. Using the index finger as an example, actuation of indexfinger slide 1806 correspondingly articulates effector joints 1812A,1812B, as described further below. Articulation of base joint 1813,correspondingly articulates effector base joint 1812C in the effectorportion 1807, in the same fashion as described for the base joint in thefinger loop variation. Cables (not shown) running from finger slides1806 and base joint 1813 through handle portion 1805, shaft 1815, andeffector palm 1816, are actuated by the user's finger movement toproduce a corresponding movement of the effector portion 1807. Mirroredmovement at the effector portion 1807 may be generally achieved byrotating the cables approximately 180.degree. as they travel throughhandle portion 1805, shaft 1815, and effector palm 1816. The shaft canbe of varying length and can be rigid or flexible, as circumstanceswarrant.

As briefly mentioned above, the arrangement of the finger portions onthe handle portion of the interface may vary to improve ergonomics ordepending on factors such as user preference or the type of procedureinvolved. For example, as shown in FIG. 21, the thumb slide 2101 ismated to the handle portion 2102 at a position different from that shownin FIGS. 14-20. In a particularly ergonomic configuration, asillustrated in FIG. 21, the position of the thumb slide 2101 is lowerthan the index finger slide 2103 and middle finger slide 2104, and insome instances, also lies posterior to these slides.

The general configuration of the finger slides may vary depending onmany user-associated factors such as ergonomics and user preference, butare usually configured to include a holder, a slider, a transmissionrod, and a pulley lever, such that translational movement of the holderproduces rotational movement of the pulley lever, which in turn movesconnecting cables to actuate effector joints and links.

In the variation illustrated in FIG. 22, finger slide 2200 includes ahousing 2201, a track 2202 along housing 2201, a holder 2203, atransmission rod 2204, a pulley lever 2205, and a slider 2206. Slider2206 is coupled to housing 2201 by dowel 2211 placed through slider 2206and track 2202 to prevent slider 2206 from rotating with respect tohousing 2201. Holder 2203 is coupled to slider 2206 at pivotable hinge2207 that accommodates finger flexion and extension. The tip of a digitmay be placed in holder 2203, and upon flexion or extension of the PIPand DIP joints, movement of the holder 2203 causes translationalmovement of slide 2206 along track 2202. This slide movement translatestranslational movement of the transmission rod 2204 into rotationalmovement of pulley lever 2205, thereby pulling cables (not shown)connected to pulley lever 2205 to cause movement of the effector portionas further described below. The holder 2203 depicted in FIG. 27 has atop plate 2208 and bottom plate 2209 for removably securing thefingertip of a user. The holder configurations of this invention,however, not only include the structure shown in FIG. 27, but alsocontemplate loop-type structures 2310 (FIG. 23), or any configurationsuitable for removably securing the fingertip of a user for actuation ofthe device. In this and other variations, base joint 2210 extends fromhousing 2201 and may be rigidly fixed to housing 2201 or formedintegrally therewith. As previously described, joints such as base joint2210 are configured to function similar to MCP joints having at leastmovement in two degrees of freedom. Finger slide actuation correspondsto articulation of DIP and PIP joints which are generally known to movein a single degree of freedom.

Another finger slide variation is shown in FIGS. 23 and 24, and in FIGS.18-21. In this variation, finger slide 1806 includes a housing 2301 withslide pins 2302, a curved slide 2303, a transmission rod 2304, a pulleylever 2307, a holder 2310, and pulleys (not shown). The provision ofcurved slide 2303 is particularly ergonomic because in operation theoverall motion of the finger slide takes a curved path that mimics thepath a user's fingertips make when the PIP and DIP joints are bent.Furthermore, use of this curved slide path more accurately mimics humanfinger movement because with this configuration, a user's DIP and PIPjoints can be articulated without moving the MCP joint. For example,referring back to FIG. 20, actuation of effector joints 1812A and 1812Bcould easily occur independently of actuation of effector base joint1812C. The curve of slide 2303 may be adapted to be a circular arc,ellipse, parabola, and the like, in order to achieve this motion.

With respect to other features of finger slide 1806, slide pins 2302insert into track 2308 to couple curved slide 2303 to housing 2301.Pulley lever 2307 is pivotably connected to housing 2301 by a firstdowel 2309. A transmission rod 2304 having a proximal end 2305 and adistal end 2306 operably connects pulley lever 2307 to holder 2310. Asecond dowel 2311 couples transmission rod proximal end 2305 to pulleylever 2307. At distal end 2306, transmission rod 2304 is pivotablyconnected to curved slide 2303 by a third dowel (not shown). In FIG. 23,a base joint 1813 that is rigidly fixed to housing 2301 is also shown.

In FIG. 24, the relationship of additional finger slide elements to eachother is more clearly depicted. As shown in FIG. 24, finger slide 1806includes a curved slide 2303 having a distal end 2313. Distal end 2313is fixedly connected to bracket 2314. Plate 2315 has a cylindricalopening 2316 that receives mandrel 2317, such that plate 2315 can rotateabout mandrel 2317. Mandrel 2317 is pivotally coupled to bracket 2314 bydowel 2318. Plate 2315 can thus both pivot and rotate relative tobracket 2314, i.e., it can pivot about dowel 2318 as well as rotaterelative to mandrel 2317. Holder 2310 is secured to plate 2315 and thuscan also pivot and rotate with respect to bracket 2314. This fingerslide configuration is particularly ergonomic because it accommodatesnatural finger movement when the fingers are abducted. The ability ofthe finger holder to rotate relative to the slide, in particular, isadvantageous as it more readily accommodates a combined flexion andabduction movement between fingers during which the fingertips naturallyrotate slightly relative to one another.

The finger slide of FIG. 23 also includes cables for actuating movementof the effector portion as shown in the cross-section taken along lineB-B in FIG. 25 and in FIG. 26. Cables 2503 and 2504 wrap around pulley2317 and terminate in pulley lever 2307. Cables 2501 and 2502 wraparound pulley 2318 on the opposite side of pulley lever 2307 andsimilarly terminate in pulley lever 2307. In operation, flexion orextension of a user's finger at the DIP and PIP joints, e.g., an indexfinger, secured to the finger slide, causes a rotational movement ofpulley lever 2307 which thereby freely pulls cables 2501 and 2502 aboutpulley 2318, and freely pulls cables 2503 and 2504 about pulley 2317.More specifically, when a user's index finger is flexed at the DIP andPIP joints, cable 2501 is pulled about pulley 2318 and cable 2503 ispulled about pulley 2317. When a user's index finger is extended at theDIP and PIP joints, cable 2502 is pulled about pulley 2318 and cable2504 is pulled about pulley 2317. Cables 2501, 2502, 2503, and 2504 thenpass through channels 2604 in base joint 1813 to articulate movement ofeffector joints (e.g., joints 1812A and 1812B in FIG. 30) as furtherdescribed below.

The pulleys may be configured to rotate about dowel 2309 or may befixedly attached to pulley lever 2307, and generally have diameters thatvary from one another.

In some instances, it may be desirable to scale movement of theeffectors in relation to movement occurring at the user interface.Typically, pulley diameters are selected so that the amount of cablepulled for a given rotation is equal to the cable that would be pulledif an articulating link were substituted in place of the pulley. Thus,because cables that actuate a most-distal effector link (e.g., 1811A inFIG. 20) usually travels farther than cables that actuate another distaleffector link (e.g., 1811B in FIG. 20), the diameter of the pulley thatcontrols the most distal effector link must be larger than that of thepulley that controls the distal effector link. For example, in FIG. 25,pulley 2318 is shown to have a diameter approximately twice that ofpulley 2317. Scaling of effector movement can be further adjusted byvarying the pulley diameters while retaining the same ratio of thepulley diameters relative to one another and/or varying the ratio of thepulley diameters relative to one another. In addition, although thepulleys in FIGS. 25-26 are circular, other pulley shapes may be employedto adjust movement of the effector joints. For example, a cam shape maybe used to articulate an effector joint in a non-linear fashion.

Referring to FIG. 26, another way to scale effector movement is toadjust the position of transmission rod 2304 along the length of pulleylever 2307 by lifting distal end of transmission rod 2305 closer topulley 2317 such that dowel 2323 inserts into one of dowel apertures2317. Effector movements will be scaled down as distal end 2305 ispositioned closer to pulley 2505. Other ways to scale movement of theeffectors include, but are not limited to, the inclusion of additionalspacer links and/or varying the cable channel pattern radius in thelinks, as previously discussed. In some instances, e.g., in industrialapplications, reverse scaling may be desirable.

Movement of base joint 1813 is actuated by the user's fingers. Aspreviously described, movement of base joint 1813 results in acorresponding movement at an effector base joint (e.g., 1812C in FIG.20). The cables used to connect base joint 1813 to an effector basejoint, cables 2601, 2602, and 2603, terminate as shown on base joint2813 in FIG. 26. Cable termination at the effector portion will befurther described below.

All cables leaving the finger portion of a user interface travel througha handle portion, shaft, and an effector palm before terminating at aneffector link. As mentioned above, in order for movement to be mirroredat the distal end of the device, cables traveling from the proximal endare generally rotated approximately 180.degree. prior to terminating atthe distal end. However, in certain applications, because a combinationof mirrored and inverted movement may be desired, all cables do notnecessarily have to be rotated. In addition, in single degree of freedomjoints, e.g., a joint corresponding to a DIP or PIP joint, the cables donot have to be rotated 180.degree. in order to provide mirroredmovement. The cables simply need to be moved to the other side of thepivot or hinge on one link of the pair relative to cable position on theother link of the pair.

FIG. 27 depicts cable rotation through handle portion 1805 by noting theentry and exit points of cables in handle portion 1805. In FIG. 27,cables enter handle portion 1805 in the general pattern shown at a firstarea 2703. For example cable 2602 is shown to enter first area 2703 atapproximately the 2 o'clock position, and 2603 at the 5 o'clockposition. Upon exit at a second area 2702, a different cable pattern isseen. Instead of exiting at the 2 o'clock position, cable 2602 exits atapproximately the 8 o'clock position, and for cable 2603, instead ofexiting at the 5 o'clock position, it exits at approximately the 11o'clock position. A rotation of 180.degree. is needed only if mirroredmovement is desired. Otherwise, cables may be rotated in any manner tosuit the intended use of the device.

The handle portion 2802 of the user hand interface may be a moldedhandle, as shown in FIG. 28, with channels or tubes 2801 for routingcables. In this variation, instead of rotating cables, the channels maybe rotated or crossed to effect mirrored or inverted movement. Inanother variation, as shown in FIG. 29, the handle portion 2901 may behollow and include a pulley 2902 for alignment and routing of cables2903. The cables 2903 in this variation can be rotated (crossed) eitherbefore reaching pulley 2902, or after travel around pulley 2902.Materials that may be used to make the molded or hollow handles of thisinvention include those previously described for elongate links, as wellas others that may be suitable for making medical devices.

The effector portion of the device typically includes three effectorsthat correspond to a user's index finger, middle finger, and thumb, butany number of effectors may be included. As generally described, cablestraveling from the user interface variously terminate at effector linksto actuate effector movement. An understanding of joint articulationusing a finger slide may be better obtained by viewing the cabletermination points shown in FIG. 30 in conjunction with FIGS. 18-20. Theeffector portion depicted in FIG. 30 represents effector portion 1807 inFIGS. 18-20. Although the general structure and operation of effectorsin the finger slide variation are being described, it is understood thatthis structure and operation also applies to the interface variationhaving finger loops.

In FIG. 30, effector 1808 corresponds to a user's index finger, and isgenerally configured to include an effector base joint 1812C, twoeffector joints 1812A and 1812B, and effector links 1811A, 1811B, and1811C. Effector link 1811C corresponds to the proximal phalanx of anindex finger; effector link 1811B corresponds to the middle phalanx ofan index finger; and effector link 1811A corresponds to the distalphalanx of an index finger. Similarly, effector base joint 1812Ccorresponds to a MCP joint capable of movement in at least two degreesof freedom, effector joint 1812B corresponds to a PIP joint capable ofmovement in a single degree of freedom, and effector joint 1812Acorresponds to a DIP joint, also capable of movement in a single degreeof freedom. As depicted in FIG. 34, effector link 1811B, which isrepresentative, is formed by securing links 3101 to the ends of a tube,although other methods of forming the effector links will be readilyapparent.

Cables from the handle portion of the device are received through shaft(not shown) and are routed to the appropriate effector by effector palm1816. Effectors emerge from effector palm 1816, as shown in FIG. 30 andother figures, that extends from the shaft. However, if desired, theeffectors may be adapted to emerge from different points along the shaftor effector palm 1816 to form, e.g., a staggered or more spread outeffector configuration. In this manner, a more or less hand-likeeffector portion can be made. Typically, cables 2501, 2502, 2503, and2504 from the slider which actuate movement of effector joints 1812A and1812B, terminate at one of the two effector links 1811A and 1811B. Forexample, as more clearly shown in FIG. 31A, cables 2501 and 2502 whichare pulled around the larger pulley, and which articulate movement ofeffector joint 1812A, terminate in distal-most effector link 1811A.Cables 2503 and 2504 which are pulled around the smaller pulley, andwhich articulate effector joint 1812A, terminate in effector link 1811B,as shown in FIG. 31B. Likewise, cables 2601, 2602, and 2603 originatingfrom base joint (1904 in FIG. 20) and which articulate movement ofeffector base joint 1812C, generally terminate at effector link 1811C,as depicted in FIG. 31C.

Effector joints 1812A-1812C are typically configured to have a range ofmotion that mimics the range of motion of MCP, PIP, and DIP joints,respectively. For example, effector base joint 1812C which correspondsto an MCP joint, is typically equipped to move in at least two degreesof freedom by including, e.g., two or more links 3105 each having a rib3106 extending from the diameter of one surface of the link and havingchannels 3104 running across the diameter of their opposite surface.Channels 3104 are adapted to pivotably engage rib 3106 along the entirelength of the channel, such that two links can pivot relative to oneanother about the axis of the channel. In effector base joint 1812C, thetwo links are positioned with their respective ribs oriented orthogonalto one another and with the rib of the most proximal link engaging asimilar channel provided in effector palm 1816, in order to providemovement in two degrees of freedom. Distal effector joints 1812A and1812B generally only require movement in a single degree of freedom.FIG. 33 is representative of effector base link 1812C also shown inFIGS. 30 and 31C. Another representative joint structure providing asingle degree of freedom is depicted in FIGS. 31A-31B, and FIG. 32 andincludes links 3101 having a rib 3102 extending from the diameter of onesurface of the link and having a channel 3103 aligned with the extendingrib on its other side. Channels 3103 are adapted to pivotably engage rib3102 along the entire length of the channel, such that two links canpivot relative to one another about the axis of the channel, to providea single degree of freedom.

Importantly, the finger portion of the interfaces described above may beconfigured to include a combination of finger slides and finger loopsfor articulation of effector joints. For example, because thumb jointscan generally move somewhat independently from one another, a fingerloop type finger portion may provide more accurate mimicking of humanthumb joint movement at the effector. This is because finger loop inputcontrol allows for independent control of distal effector link movement,in contrast to finger slides which only allows coupled control of distaleffector link movement. On the other hand, when DIP and PIP joints offingers such as the index finger, middle finger, and ring finger, arearticulated, they usually flex or extend together. Accordingly, it maybe more suitable for finger slides to actuate effector movement forthese fingers.

It is also understood that the hand-actuated devices may also adoptconfigurations that differ from the human hand. For example, in certainsurgical applications, it may be desirable to shape the effector portionin such a way that it becomes a tool with functionality other than thatof gripping of the hand.

In yet another variation, the articulating mechanism may be used for theendoscopic treatment of atrial fibrillation. In particular, thearticulating mechanism of the invention can be adapted to facilitate thecreation of ablative lesions in heart tissue, which has beendemonstrated to be effective in treating atrial fibrillation, asdescribed e.g. by Cox, J. L. (2000). “Minimally Invasive Maze-IIIProcedure,” Operative Techniques in Thoracic and Cardiovascular SurgeryVol. 5(1):79-92; Simha et al. (2001). “The Electrocautery Maze—How I DoIt,” The Heart Surgery Forum Vol. 4(4):340-345; and Prasad et al.(2001). “Epicardial Ablation on the Beating Heart; Progress Towards anOff-Pump Maze Procedure,” The Heart Surgery Forum Vol. 5(2):100-104; andas described in U.S. Pat. No. 6,161,543 to Cox et al. Such procedurescan include epicardial or endocardial ablation, and many such proceduresrequire accessing the posterior of the patient's heart, which can bedifficult. The articulating mechanism of the invention can be configuredwith an ablative element, and together with its ability to form complexgeometries; the mechanism can be readily navigated through thesurrounding anatomy of the heart and easily positioned at variouslocations in or on the posterior of the heart to facilitate suchablation therapy.

Articulating mechanism 131 shown in FIG. 12A includes ablative element125 connected to an electromagnetic energy source (not shown), such asan energy source which generated energy in radiofrequency (RF) ormicrowave frequency ranges. Such ablative elements are well known in theart, including those generally described in U.S. Pat. No. 6,471,696. Theablative element is mounted to links on the distal end 141 of themechanism by way of attachment member 134 which is fittingly engagedwith in channels 144 of links 142. The ablative element includes aninsulated portion 127, typically formed of a thermoplastic elastomer,with longitudinally extending antenna or wire 129 for transmittingenergy into tissue disposed therein. Other antenna or wire geometries,including helical coils, printed circuits, and the like are equallyeffective. Insulated conducting leads 136 and 137 are provided forconnecting the energy source to the antenna or wire in a monopolarconfiguration. Bipolar configurations are also contemplated. Additionalconnectors 138 and 139 to the ablative element are also provided and canfunction in a variety of capacities, such as providing temperature orother sensors or probes, or to deliver a cooling medium to the elementto cool the surrounding tissue and prevent extensive tissue damage, asis described, e.g., in U.S. Patent Application Publication No. US2003/0078644 to Phan.

FIG. 12B shows another variation of the articulating mechanism of thepresent invention configured for ablation. In this variation,articulating mechanism 133, which is configured for bipolar use,includes distal end 143 having distal links 152 that contain opposingelectrodes 159. The opposing electrodes are separated by channel 164.Insulated conducting leads, such as leads 166 and 167, connect each pairof electrodes to the energy source (not shown). When energized, energyis transmitted across the electrode pairs, creating ablative lesions inthe surrounding tissue. Again, additional connections 168 and 169 arealso provided to provide additional functions, including probes,sensors, and cooling fluids.

While the above variations use ablative elements that rely onelectromagnetic energy, articulating mechanisms according to theinvention can also be readily adapted to incorporate other methods ofablation known in the art. For example, the ablative element could be acryogenic or ultrasonic probe, or ablative elements that use laserenergy, or other known ablative techniques.

Epicardial ablative lesions can be created as shown in the exampledepicted in FIGS. 13A-13F. Access to the posterior of a patient's heart929 by articulating mechanism 131 may be initially made through, e.g., athoracotomy, mini-thoracotomy, or trocar port (e.g., a 5-10 mm port),placed in the anterior chest wall of a patient. The spacer element (notshown) of the articulating mechanism may serve the purpose of a fulcrumat the port. As the surgeon bends the proximal links that are outside ofthe patient, the distal links inside the patient mimic the curvature ofthe outside links in a reciprocal fashion, in order to wrap around thesuperior vena cava 933 (13A) and continue to surround and the pulmonaryveins 935 (13B) as the articulating mechanism is simultaneouslyadvanced. Once in position, as shown in FIG. 13B, the ablative elementon the distal end of the articulating mechanism can then be activated tocreate a lesion, and as depicted here in particular, pulmonaryencircling lesion 943 (FIG. 13C). In FIGS. 13D and 13E the articulatingmechanism is shown being repositioned to extend downward from thepulmonary veins 935 to create a lesion 939 down to the mitral valveannulus that connects to prior-formed pulmonary encircling lesion 943(FIG. 13F).

The invention also contemplates kits for providing various articulatingmechanisms and associated accessories. For example, kits containingarticulating mechanisms having different lengths, different segmentdiameters, and/or different types of surgical instruments, or differenttypes of locking rods or malleable coverings may be provided. The kitsmay be tailored for specific procedures, e.g., endoscopy, retraction, orcatheter placement, and/or for particular patient populations, e.g.,pediatric or adult.

All publications, patents, and patent applications cited herein arehereby incorporated by reference in their entirety for all purposes tothe same extent as if each individual publication, patent, or patentapplication were specifically and individually indicated to be soincorporated by reference. Although the foregoing invention has beendescribed in some detail by way of illustration and example for purposesof clarity of understanding, it will be readily apparent to those ofordinary skill in the art in light of the teachings of this inventionthat certain changes and modifications may be made thereto withoutdeparting from the spirit and scope of the appended claims.

1-10. (canceled)
 11. A medical instrument comprising: a distalarticulation mechanism including a plurality of distal segments movablerelative to each other; an actuatable element coupled to the distalarticulation mechanism; a proximal articulation mechanism including aplurality of proximal segments, each proximal segment forming a pairwith a corresponding distal segment from the plurality of distalsegments; a user interface coupled to the proximal articulationmechanism, wherein the user interface manipulates the actuatableelement; and multiple sets of cables, each set connecting the proximalsegment and the corresponding distal segment of one of the pairs andterminating at the segments of the pair, such that movement of theproximal segment causes corresponding relative movement of thecorresponding distal segment of the pair.
 12. The medical instrument ofclaim 1 wherein the actuatable element includes a pair of jaws.
 13. Themedical instrument of claim 1 wherein the actuatable element includes acutting element.
 14. The medical instrument of claim 1 wherein theactuatable element includes a stapling device.
 15. The medicalinstrument of claim 1 wherein the actuatable element includes anablation device.
 16. The medical instrument of claim 1 wherein theactuatable element includes a grasping device.
 17. The medicalinstrument of claim 1 wherein the user interface includes a pivotmechanism.
 18. The medical instrument of claim 1 wherein the proximalarticulation mechanism is coupled to the user interface distally of thepivot mechanism.
 19. The medical instrument of claim 1 wherein theproximal articulation mechanism is coupled to the user interfaceproximally of the pivot mechanism.
 20. The medical instrument of claim 1wherein the user interface includes a clamp handle.
 21. The medicalinstrument of claim 10 wherein a portion of the proximal articulationmechanism extends through the clamp handle.
 22. The medical instrumentof claim 1 wherein the at least one set of cables is bifurcated toconnect one of the proximal segments to a corresponding distal segmenton each of two portions of the actuatable element such that movement ofthe proximal segment causes corresponding relative movement of both ofthe corresponding distal segments, whereby both of the portions of theactuatable element can be articulated into a common desired shape bymanipulation of one or more proximal segments.
 23. The medicalinstrument of claim 1 wherein the two portions of the actuatable elementform a pair of jaws.
 24. The medical instrument of claim 1 wherein atleast one of the jaws includes an ablation element.
 25. The medicalinstrument of claim 1, wherein the plurality of distal segments aregenerally aligned along a first common axis and the plurality ofproximal segments are generally aligned along a second common axis, thefirst axis being non-parallel to the second axis.
 26. The medicalinstrument of claim 15, wherein the first axis is generallyperpendicular to the second axis.
 27. The medical instrument of claim 1,wherein the plurality of distal segments are generally aligned along afirst common axis and the plurality of proximal segments are generallyaligned along a second common axis, the first axis being generallyparallel to the second axis.
 28. The medical instrument of claim 1further comprising a spacer element between the proximal and distalarticulation mechanisms.